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From the Townsend Letter
February / March 2018

Cortisol Deficiency: Frequent, Life-Impairing, and How to Give Patients Their Lives Back by Correcting It Part 2
by Thierry Hertoghe, MD
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Part 1, the signs and symptoms, is online.

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To Treat or Not to Treat Cortisol Deficiency?
People with cortisol deficiency who do not get treatment continue suffering from the psychic and physical consequences of cortisol deficiency at every moment of their lives. In the long term, the absence of treatment permits the cortisol deficiency to aggravate and produce chronic inflammatory diseases such as rheumatoid arthritis and psychological disorders, from irritability to the extreme form of paranoid psychosis. Because of the adverse consequences of not treating cortisol deficiency, forgoing treatment is not really an option.

Natural Treatments to Improve Cortisol Levels
The first natural treatment to get a higher cortisol level is to increase light.154 After moving from a dark room into full daylight, an individual's cortisol level increases by 50% or more within minutes. Thus, the golden rule is to expose oneself to more light: switching all the lights on in the office and at home and going outdoors at least once a day in full daylight for a minimum of half an hour. This quickly increases not only cortisol levels but also the number of cortisol receptors.

Second, it is of great importance to breathe cleaner air and eat organic foods to avoid airborne and foodborne pollutants, as toxins usually aggress the zona fasciculata of the adrenal glands that produces cortisol or block the target cells' glucocorticoid receptors, inhibiting part of the action of cortisol.

One of these irritant pollutants is formaldehyde,155 which pollutes many homes and offices. It is part of many types of glue that fix floor coverings to the ground and bind compressed wood together in home and office furniture. It is often part of plastic carpets and toys and slowly outgasses from these objects into the indoor atmosphere over the years, being inhaled through breathing. What to do about it? Apart from getting rid of these formaldehyde-containing materials inside homes, simply open the windows in rooms where such materials are and let outdoor air enter. Regularly ventilating rooms with outdoor air drastically reduces the formaldehyde concentration in the indoor air and, thus, the risk of adrenal gland damage.

Third, increasing the consumption of protein-rich foods,156-157 such as meat, poultry, and fish, and fat-rich foods,158-161 such as eggs, yolk, butter (preferably clarified butter), liver, and other organ meats, elevates the cortisol production and level by providing the ingredients for production of cortisol. Augmenting protein is not always easy with patients with cortisol deficiency, as they tend to accumulate nitrogen in the blood by consuming these nitrogen-rich foods. Indeed, once they consume meat and other protein-rich foods, the high level of nitrogen in their blood (azotemia) gives them nausea and disgust for meat. Fat intake also poses problems, as fats seem hard to digest by these patients, frequently causing indigestion. The solution consists of correcting the cortisol deficiency with a cortisol supplement and encouraging the patients to increase the intake of the protein- and fat-rich foods they tolerate.

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People with cortisol deficiency should also avoid "bad" carbs, carbohydrate-rich foods that reduce the production of cortisol, like sweets, sugars,162 unsprouted bread, muesli, porridge, and rice. These foods can reduce the secretion of cortisol by 20–40%, enough to create problems. If ever they give in to the temptation of a chocolate bar or soft drinks, let them do it after a healthy meal, which dilutes the sugar into a bigger volume, reducing sugar's hyperglycemic effect that blocks cortisol production (peak levels of glucose inhibit cortisol release).

Klaire LabsFourth, some rare nutritional supplements can help the adrenal glands function better, although modestly. Vitamin C is one of them.163-164 With 500 mg to 2 g of vitamin C a day, the action of cortisol may get a boost. L-acetyl-carnitine, the activated form of L-carnitine, is another nutrient whose intake has been shown to significantly increase serum cortisol levels in humans.165 A dose of 2 g/day may be efficient.

Fifth, several herbal extracts may weakly mimic cortisol activity by increasing its bioavailability and stimulating cortisol receptors, providing limited relief to adrenal-deficient patients. Plants also produce hormones that may have beneficial effects in humans. Extracts of licorice root may, for example, lessen complaints in patients with cortisol deficiency.166-167 In my experience, licorice root extract has about 10-25% of the beneficial action of an adequate cortisol or hydrocortisone treatment.

Sixth, as the storage of cortisol in the adrenal glands is small in patients with adrenal deficiency, these patients should avoid exposing themselves to any unnecessary stressors, which deplete the adrenals of their cortisol stores. Selecting jobs and leisure activities that do not put excessive strain on the adrenal glands may be a wise decision for people who do not get or want to take a cortisol treatment. Spiritual meditation has been reported to be helpful in improving cortisol levels. Regular meditators respond to stressful conditions with a greater production of cortisol than non-meditators, while the cortisol level is lower in resting states, minimizing spillage.168

Table 1 summarizes the main interventions you can do yourself with the help of a nutritionist to improve your cortisol secretion.

Table 1. Interventions to Improve Cortisol Secretion

  • Increase light: daylight, intense indoor light, sunny holiday resorts
  • Increase fat-rich foods (butter, egg yolk, liver, etc.)
  • Take vitamin C supplements: 0.5 to 2 g/day
  • Avoid indoor pollutants: stay away from plastic furniture or floor coverings, wood preservatives; keep windows open
  • Reduce unhealthy carbohydrate-rich foods (sugar, sweets, chocolate, unsprouted bread, muesli, porridge, rice, pasta, soft drinks, alcohol)
  • Herbal extract of licorice root: 450 to 1800 mg/day
  • Increase protein-rich foods (fish, poultry, meat)
  • Increase fruit intake (contains vitamin C, which may increase adrenal function)
  • Avoid unnecessary stressful conditions (which deplete cortisol stores); regularly relax or meditate

Glucocorticoid Treatment of Cortisol Deficiency
Glucocorticoid is the common name given to the whole family of natural or synthetically produced cortisol-like molecules, which share the property of increasing the blood sugar levels. "Gluco" means "glucose" (sugar), and "corticoid" signifies that it "comes from the cortex," the outer part of the adrenal glands that produces this type of hormone. The human body makes two major bioidentical glucocorticoids: cortisol and cortisone. Bioidentical means that these hormones have the same molecular structure as the body's own corresponding compounds. Corticosterone, which in rodents is more potent than cortisol, is another natural hormone that is found in humans.

Cortisol, also called hydrocortisone when it is used in therapy, is the body's most potent glucocorticoid hormone. Cortisone is the precursor glucocorticoid made by the adrenals. It has 80% of cortisol's action. Supplementation with cortisone is therefore always at a slightly higher dosage than with cortisol or hydrocortisone to get the same effects: To do the same job, 25 mg per day of cortisone is needed where the body requires 20 mg of hydrocortisone.

However, the name cortisone is misleadingly used nowadays to name synthetic derivatives of cortisol, such as prednisone and methylprednisolone. These compounds are not identical to the body's own cortisol and cortisone. They may have different effects and indications. They are also used at lower dosages, as they have more potent effects.

Bioidentical glucocorticoids have better psychological effects and improve the blood pressure better than synthetic derivatives. The use of bioidentical cortisol and cortisone is indicated to treat most cases of cortisol deficiency, particularly when the predominant complaints are psychological. Bioidentical glucocorticoids better improve the mind, mood, energy, stress resistance, and other personality features compared to non-bioidentical glucocorticoids169-172 because they are entirely adapted to the human body, particularly its glucocorticoid receptors.

Hydrocortisone is also a better choice to treat arterial hypotension because it retains salt and water more than synthetic derivatives.

Safety of Bioidentical Hormones
Because cortisol and cortisone are completely adapted to the human body, they are also safer. The risk of side effects such as skin atrophy is lower with these bioidentical glucocorticoids than with synthetic derivatives.173 Long-term behavioral outcome and neuromotor development are also better in children who neonatally have received hydrocortisone rather than synthetic dexamethasone to avoid bronchial dysplasia.172 Whenever side effects, usually overdose symptoms, occur with these natural compounds, they persist for a shorter time (6-24 hours) because of a quicker breakdown and inactivation by the body than when caused by synthetic derivatives (a few days). For this reason, at comparable doses, cortisol and cortisone reduce the endogenous cortisol production of the adrenal glands considerably less than synthetic derivatives. The risk of adrenal gland suppression is also less with bioidentical glucocorticoids.51,174-175

Table 2 (adapted from Chrousos et al., 2011)51 shows that synthetic derivatives of cortisol at equivalent doses suppress the adrenal glands more. The greater their glucocorticoid (and thus anti-inflammatory) potency, the more they suppress the endogenous cortisol secretion.

Table 2. Comparison of Synthetic Cortisol Derivatives .pdf

The safety of all these glucocorticoids is greatly increased with the use of lower doses of glucocorticoids, such as 30 mg/day or less of hydrocortisone and 5 mg/day or less of prednisolone.28

Non-bioidentical glucocorticoids reduce inflammation better but may suppress the adrenal glands more. Non-bioidentical glucocorticoids, such as prednisone, prednisolone, methylprednisolone, and dexametha-sone, are more indicated than bioidentical cortisol whenever inflam-mation prevails. Indeed, these compounds reduce inflammation more efficiently and persistently due to their (much) longer duration of action, usually 24 hours or more after intake (see table above).51,56,176-178 A good strategy is to prescribe them for a limited time (2–6 months is the time necessary to reduce the inflammation) and then switch to bioidentical cortisol once the inflammation is gone.

As previously mentioned, there are two bioidentical hormones available at pharmacies: cortisol (usually delivered under its synonym, hydrocortisone) and cortisone (the precursor to cortisol, with 20% less potency). In most cases, for patients with no tendency toward high blood pressure, being overweight, or swelling of the feet, hydrocortisone is the preferred treatment.179 The science behind bioidentical cortisol treatment is strong. Pubmed, the main Internet medical databank, presents 270 placebo-controlled studies in adults (almost all double-blind; 256 with systemic therapies,180-433 14 with topical therapies434-447).

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